you're doing it wrong

Yesterday’s social media furore over a dodgy letter to the Observer left me questioning my place within the women’s movement for the umpteenth time. However, within hours I was powerfully reminded that those who advocate an exclusive feminism are less influential and important than they might like to think.

Last night I joined a room of people committed to building a feminism that is compassionate, reflexive, inclusive of all women and sensitive to our different experiences.

Last night I found myself in a room of brown, black and white faces; gay, bi and straight; cis and trans; working class and middle class; disabled and abled. Last night I heard a teenage Muslim woman speak out about the importance of representing all faiths in activism after a question from a Jewish woman in the audience. Last night I heard from a white middle-class straight woman who has turned up to learn with an open mind. Last night I heard cis women talk about about trans rights, and felt that my identity and experience as a woman was simply not in question.

I had been invited to contribute to a panel discussion at the University of Bristol Students’ Union (UBU). Entitled How do we make the Women’s Movement intersectional?, the panel was was of UBU’s “Festival of Liberation“, which also includes events looking at the challenges faced by LGBT people, disabled people, and people of colour. I was honoured to share a panel with three truly awesome women: Susuana Antubam and Sammi Whitaker of the NUS Women’s Campaign, and Fahma Mohamed of Integrate Bristol.

Last night was promising and encouraging and heartwarming, and was not unusual in being so. I have seen similar scenes repeated across the country over the last few years at talks, workshops, protests and riot grrrl gigs.

This is the new feminism. A feminism that is discarding the model of monolithic female oppression and in its place building a movement around diversity and inclusion. A feminism that seeks to base both theory and action upon what different groups of women have to say about their lives and experiences, rather than imposing a top-down model of liberation drawn from academic theory. A feminism that sees cis and straight women take responsibility for supporting the work of their trans and queer sisters, white women take responsibility for supporting the work of their sisters of colour, abled women take responsibiity for supporting the work of their disabled sisters and so on.

Last night we talked about the importance of intersectionality as feminist praxis: of putting ideas into action. We talked about the importance of education: of sharing the knowledge and tools necessary for women’s liberation with people of all genders. We talked about the importance of representation: of working to ensure that women of all backgrounds feel welcome and able to attend feminist events through the use of accessible venues, ensuring diversity within organising teams and (where relevant) speakers/acts, and thinking about the language we use. We talked about the benefits of building groups around intersectional identities (such as black womanhood); groups that can then work alongside other bodies of people with a broader remit, feeding in ideas and holding them to account.

We talked about calling people out and challenging oppressive behaviour both within wider society and within the feminist movement. We also talked about being kind and prepared to forgive, and allowing people space to learn and grow. We talked about how everyone will make mistakes, because intersectional feminism is a constant experience of doing and being, rather than a closed process where you jump through a series of hoops and then become a Good Feminist who is capable of always passing judgement upon others.

We talked about our experiences of activism. Fahma talked about giving a piece of her mind to a nervous Michael Gove, resulting in a letter to every school in the country about FGM. Sammi talked about productive conversations with working class male friends, and building liberation into the very fabric of Anglia Ruskin’s fledgling Students’ Union. Susuana talked about her work on addressing lad culture as a gendered, racialised and classist phenomenon. I talked about my contributions to trans and non-binary inclusion within the NUS Women’s Campaign, and how we seek a diverse range of performers for Revolt, Coventry’s feminist punk night. We heard stories and ideas and questions from the audience, and I reflected on how we were not “experts” with a monopoly on solutions, but just one part of a wider movement.

These are just some of the things that we talked about.

So why have I been led to question my place within the women’s movement?

When I read things like this, I am repelled by a feminism that is harsh, bitter and exclusionary.

When feminists gaslight me by claiming repeatedly that the individuals who wrote these articles are not transphobic I am saddened and confused.

When I hear about feminists disrupting conversations at events such as AFem in order to promote an agenda that excludes trans people and sex workers, I am disappointed and worried.

When I see exclusionary events like Radfem 2013 and Femifest 2014 promoted within feminist spaces and supported by organisations like Women’s Aid and Reclaim The Night London I am alarmed and concerned.

When I see feminist women and men – including both public figures as well as personal friends and acquaintances – sign a misleading letter that condemns attempts to debate and contest the above, I wonder how voices of those who work for an inclusive and diverse feminism can possibly stand against a “letter mob” representing the discursive might of the liberal Establishment.

The stakes are high. Too many of my friends have considered suicide. Too many of my friends have died. When I talk to my trans friends and fellow activists, I hear about fragile mental health, doctors and shopkeepers refusing to provide services, threats of violence and attacks in the street. All of these things are fuelled by the dehumanisation of trans people, the idea that we require intervention to save us from the misguided path of transition, the implication that we do not deserve to exist within public spaces. These discourses are perpetuated by feminists and defended by liberals in the name of “free speech”.

I don’t believe in historical inevitability and don’t buy into progression narratives. I had a debate about trans-exclusive feminisms with Jack Halberstam recently. Jack echoed my PhD supervisor in arguing that trans-exclusive feminisms are outdated and irrelevant, long-dismissed within the academic world. But the academic world is often divorced from the reality of the feminist movement on the ground. In this reality, exclusive feminisms continue to fester.

In spite of all of this, last night reminded me of the power and appeal of the new, intersectional feminism. It is this feminism that is popular amongst young people who are more interested in working together than apart, and veteran activists with the humility to share their ideas and wisdom with newcomers on an equal footing.

This feminism requires work and nurture, but – as I argued last night – this does not need to be an entirely arduous task. Working together across our differences and ensuring that more people feel welcome and included makes us stronger. Learning new things from others can be interesting and exciting. Having the strength to learn from our mistakes solidifies friendships and alliances. Discovering a more diverse range of feminist histories, activisms and performances can be fun and empowering.

This afternoon I received an unsolicited email in my work account from an employee of Sundog Pictures. An excerpt follows:

I’m currently working on an idea alongside Channel 4 following transgender individuals who have come to regret their sex changes and are keen to undergo further treatment / operations to reverse the change. The doc will be insightful and sensitive and will look at the way in which transgender individuals are treated in society and whether the process before someone is permitted an operation is robust enough.

I’m currently looking for real life cases to include in my pitch document and was wondering whether you might be able to recommend people I could speak to, or places I could contact to find individuals who are currently thinking about a reverse sex change. Any help would be really appreciated.

Given the email account used, I feel that I can safely assume that I was contacted because of my academic work, which looks at discourses of trans healthcare provision. Sundog seem to hope that I will (without compensation) draw upon my community contacts and research findings to recommend participants for their television programme.

I couldn’t think of anything more inappropriate.

There’s a lot to be said about research ethics and a duty of care towards participants, but plenty has been written about that elsewhere (the BSA Statement of Ethical Practice offers a decent broad overview). So in this post I focus on the huge problems that come with the proposed topic of the documentary: that of trans “regret”.

The numbers

The mainstream media take an undue interest in trans “regret”. It’s very easy to come across such stories on daytime television and in both tabloid and broadsheet newspapers. The popularity and frequency of such stories suggests that it’s not too unusual for people who have undertaken a physical transition from male to female, or from female to male, to consider or undertake a “reverse sex change”.

In reality, research has shown time and time again that the actual rate of regret is extremely low. For instance, only 2% of respondents in the Trans Mental Health Study (the second-largest trans study undertaken in the UK) reported “major regrets” about the physical changes experienced during transition. Reported regrets from participants included:

“…not having the body that they wanted from birth, not transitioning sooner/earlier, surgery complications (especially loss of sensitivity), choice of surgeon (if surgery required revisions and repairs), losing friends and family, and the impact of transition on others.”

It’s clear therefore that “regret”, when it occurs, is likely to stem from societal and surgical issues rather than the process of physical transition in and of itself. The Trans Mental Health Study also demonstrates a clear link between physical transition and wellbeing in terms of mental health, body confidence and general life satisfaction.

It’s pretty clear from the email I received that that the author has not done their research. Given the existence of organisations such as Trans Media Watch and All About Trans who are entirely keen to offer advice, this does not exactly inspire confidence.

For a start, transition is conflated with “sex change”, a term that is not only most frequently associated with transphobic tabloid headlines, but is also broadly meaningless. At what point can we talk about a “sex change”? When an individual undertakes hormone therapy? Chest surgery? Genital surgery? What about individuals who transition socially, but only undergo some (or even none!) of these processes? It’s not the kind of language that suggest an “insightful and sensitive” documentary can be made.

There’s a couple of more fundamental mistakes in the proposal, however. The first is the question of “whether the process before someone is permitted an operation is robust enough”. My own initial research findings suggest that if anything, the process in question is too robust – in that patients requiring surgery are typically required to wait many years before treatment is available.

The World Professional Association for Transgender Health Standards of Care require patients to undergo at least 12 months of hormone therapy prior to genital surgery. In reality, patients in England and Wales face a substantial waiting list (sometimes lasting years) before they are able to attend an NHS Gender Clinic, where two separate clinicians are required to approve a regime of hormone therapy before it can be undertaken. An additional two opinions are needed at a later date before a referral for genital surgery can take place. There are many, many opportunities and a great deal of time for patients to consider and re-consider their option – and that’s even before we take into account the horrific scale of the current crisis in surgery provision for trans women.

The current system is not constructed to facilitate transition so much as prevent the very possibility of regret. The result is increased suffering – in terms of the mental and physical health impact upon individuals who are forced to wait many years for hormones and surgery, whilst fearing (sometimes with good reason) that they will be denied treatment on spurious grounds. It’s no surprise that the Trans Mental Health Study found that “not transitioning sooner/earlier” is a major cause of “regret”, as individuals who have waited until breaking point to transition soon discover that there is still a long, long road ahead of them.

The second fundamental problem with Sundog’s proposal is their idea that trans people who aren’t too happy with their transition might be “keen to undergo further treatment / operations to reverse the change”. This is a very binaristic notion that both stems from and reinforces the notion that transition is a one-way process, from one (binary) gender to the other. In reality, there are many people for whom transition is a complex, ongoing process. For instance, an individual who initially transitions from male to female might later feel that their identity is better understood as genderqueer, and may allow or pursue further physical changes to reflect this.

The wider political context

Given the tiny proportion of trans people who “regret” transition and the realities of service provision, the choice of a documentary about the subject appears at best to be somewhat misguided. However, the impact of insensitive coverage on this topic is such that I believe that I believe this documentary could be actively harmful, particularly as Sundog’s email asks “whether the process before someone is permitted an operation is robust enough”.

This is in part because the way in which discourses of regret are handled makes it harder for trans people to get treatment. Gender clinics in the UK require urgent intervention to make life easier for individuals who transition, not harder. Media hysteria over the possibility of regret reinforces the current system’s approach, which is to require people to demonstrate over and over again that they are trans before there is any hope of treatment.

But it’s also because discourses of regret are employed by those who campaign against trans liberation, including conservative commentators and anti-trans radical feminists who would deny funding for transition on the NHS altogether. Writers such as Julie Bindel are all too keen to use any example of individual regret to argue that transition is unnecessary mutilation, undertaken by sad, sick individuals who might have done otherwise if only they’d been given the option of, say, some form of reparative therapy.

The focus on the medical process is therefore politically loaded. Yes, some people do de-transition, and their stories are important and of worth. But these stories have yet to be told by the mainstream media in a non-sensationalised manner, in a way that doesn’t reinforce (intentionally or otherwise) a pernicious anti-trans agenda. Sundog’s proposal appears to feed right into this agenda.

This proposed documentary should not be regarded as a curiosity piece taking place in a cultural vacuum. It draws upon and will contribute to damaging and inaccurate tropes about transition. Ill-informed media accounts ultimately play a part in creating and maintaining a situation where “regret” frequently stems from the responses of friends and family, delays to transition and other negative experiences that come with transitioning in a transphobic society.

I hope therefore that any future attempts to examine trans health issues in this way will involve better research into the topic at the initial stages, and a greater sensitivity to both the personal and political consequences of exposing trans lives to media scrutiny.

A mature student* enrolled in Warwick Medical School (WMS) has just lost a formal appeal after being denied the opportunity to resit an exam.

The events that led to this outcome indicate that WMS provides poorly for trans students undergoing a physical transition, and suggest that other students with access needs are likely to face similar problems. The student in question argued that these oversights amount to indirect discrimination: a claim rejected by a committee of senior academics from the wider University.

This message this sends is that discrimination against trans people and others is acceptable at the University of Warwick.

An inappropriate request

The first sign of trouble came in September 2011 (at the start of the WMS course) when the student (who I shall henceforth refer to as “B”) was asked to attend an Occupational Health doctor at the University Hospital of Coventry and Warwickshire.

This is not a standard procedure for all students on the course, and instead related to information B had provided to WMS upon enrolment. She was informed by a secretary in WMS that: “You are not being asked to attend on the grounds of being transgender […]I can only assume that you have ticked one of the health issues boxes and the Occupational Health team are required to assess your fitness to cope with the course.”

B sought an explanation, writing: “I’m concerned that I am actually being asked to attended simply because I am TG. Under the strictest definition, transexualism is still classified as a ‘severe mental illness’ and consequently it was necessary for me to tick the corresponding box (9? – mental health).” B had commented on the form that was was trans, believing this action to be private disclosure.

Upon further enquiry, Occupational Health confirmed B’s suspicion, explaining that she was asked to attend the meeting because she had ticked the “mental health” box. The meeting was compulsory, with B being told that: “Failure to attend will result in us not being able to clear you health wise for the course“.

Conflicting messages

Ahead of the meeting, B attempted to clarify the situation in an email to an Occupational Health Nurse based in the hospital: “Just so that I’m completely clear, am I being asked to attend due to declaring that I have dysphoria of gender identity?”

The nurse’s response was: “No – it is connected with the health question you replyed yes to on the form. It has nothing to do with your gender. We work in accordance with the equality act 2010.”

B describes the eventual meeting as follows:

When the OH appointment occurred the doctor walked in, checked the notes, and then said, “Oh, you’re trans”.

At which point I said, “Oh, you’re breaching the Equality Act then,” and proceeded to lecture them on how they were breaking my rights. At which point they asserted the party like about OH being a positive thing. And I pointed out, “then in that case I could have the right to decline your invitation”.

And the appointment ended. Nothing else was discussed.

There was no good reason for Occupational Health to know that B was trans. Through the arrangement of this meeting, she was unnecessarily outed to considerable number of people, and it was implied that her trans status might upon her ability to eventually graduate as a “Warwick doctor”.

However, worse was to follow.

A limited window of opportunity

Medical degrees are typically very intense. Students on B’s course are expected to take no more than three week’s sick leave per year during their four year course and subsequent two years as a foundation doctor. The maximum holiday period available is four weeks. The only exception to this is the summer holiday period between students’ first and second years.

As of autumn 2011, B was undergoing a physical transition, funded by the NHS and overseen by Charing Cross gender identity clinic. She intended to take a brief break in order to undergo genital surgery during her time as a medical student. However, the long recovery time (patients are typically recommended to take off at least eight weeks post-op; B was recommended to take off twelve weeks because of the physical nature of her course) and short breaks permitted during the six years of medical training meant that it would be difficult for her to find time to do so.

B was informed by the Senior Tutor at WMS that the only time she could realistically take off for surgery was her first summer holiday period. As a consequence of this, she was likely to forgo any chance to resit exams failed during her first year.

Private surgery

B then approached Charing Cross about the possibility of scheduling genital surgery for the summer of 2012. At this point, she would have completed the year of “real life experience” required by the current World Professional Association of Transgender Health Standards of Care. However, her request was rejected by Charing Cross on the grounds that she would have been attending the gender clinic for less than two years at the time of surgery.

B then faced a difficult dilemma: to wait six years for surgery, or pay for a private operation in order to complete her physical transition within the timeframe effectively demanded by WMS. She eventually took the decision to spend her savings on private treatment in order to minimise disruption to her study.

The possibility of failure

Whilst considering her options, B approached a couple of tutors for advice. She was particularly concerned about the possibility of failing her exam and then missing the resit during her time in hospital. This was a valid concern: not because B is a poor student, but because resits are not exactly uncommon within medical schools. As one academic within WMS commented in email correspondence to B:

As I am sure that you are becoming aware, medical exams can be a bit of a lottery and do not necessary relate to the candidate’s ability.

B was, however, informed that she was unlikely to fail any of her modules, and decided to go ahead with the surgery.

The exam

As it turned out, B failed her exam – along with 35% of her cohort.

An investigation by WMS formally dismissed any possibility of responsibility for this on the part of course conveners and school policy. However, B’s failure is arguably down in part to the complexities of the system as much as her own work. The manner in which the exam was marked meant that B got a higher percentage of marks than some students who passed, but failed the exam after doing poorly on a couple of very particular sections.

The exam results were announced the day that B regained consciousness in hospital following her operation. She spent the next few days in email contact with WMS from her hospital bed in an attempt to safeguard her second year of university.

The response

B requested that she be allowed (like the rest of her cohort) the opportunity to resit her exam. Unfortunately, the resit was to take place whilst she was still in hospital. WMS refused to provide any means for B to take her exam remotely, and insisted that it would not be possible for her to re-take her exam individually.

It later emerged that WMS were not prepared for any student to resit an exam individually under exceptional circumstances. Their argument is that it takes 60 working hours over the course of six months to prepare an individual exam, and that it is therefore too much work to prepare more than one paper.

B was reminded that she had been made aware that she would have to re-take the year in the event of failing any exam. WMS was not prepared to make any accommodation for her exceptional circumstances.

This would seem to imply that any student at WMS who is forced to miss an exam because of transition, disability or emergency surgery would be placed in a similar position to B.

The appeal

After pursuing the case within WMS for several weeks, B eventually decided to make a formal appeal within the wider University. The appeal entailed the preparation of a case, to be scrutinised by a committee of senior academics (including several faculty heads) before a recommendation was made to the Vice-Chancellor.

B argued that the approach of WMS amounted to indirect discrimination. The Equality Act and Disability Discrimination Act (which is applicable to individuals recovering from major surgery) both insist that suitable provisions are made for individuals with a legitimate need. The inability of WMS to provide a resit for students who have a legitimate medical reason for missing the standard resit effectively makes it difficult for anyone requiring surgery to undertake particular courses.

She therefore requested the opportunity to resit her exam, or (failing that) financial support for her re-take of the first year.

After a lengthy process of assessment (including an hour-and-a-half meeting with B in which she was able to direct present her case and answer questions) the committee rejected B’s appeal.

(i) It was noted that [B] believed she required surgery as a matter of medical need;

(ii) [B] was aware that she intended to undergo surgery at the time she applied for, and subsequently enrolled on, her degree and would also have been aware of the structure of the academic year (through the School’s Code of Practice 2011) and the fact that this would limit her opportunities to undergo elective surgery

From a letter outlining the panel’s decision:

(ii) [B’s] decision to undergo private, rather than NHS, surgery was a result of her own rational choice and was not forced by the Medical School;

(iii) The Committee accepted that the structure of the academic year for the MB ChB, in which resit exams are scheduled during the long vacation, did not allow sufficient time for students requiring long-term elective medical treatment, including transgender students requiringtransition surgery;

(iv) The Committee considered that the imposition of a structured academic year applicable to students generally is proportionate to the legitimate aim of providing education and therefore does not constitute indirect discrimination against students requiring gender re-assignment under s.19 Equality Act 2010;

(v) It was noted that the University has a duty to make reasonable adjustments under s.92(6) Equality Act 2010 where a rule or practice impacts adversely on a student with a protected characteristic;

(vi) As such, the Committee deemed temporary withdrawal for an academic year a reasonable adjustment, as it is always available for students requiring long-term treatment, including students undergoing gender re-assignment;

(vii) In relation to the question whether the Medical School should prepare a special resit paper to be taken at a time convenient to [B], it was noted that it is not uncommon in other Faculties for special arrangements to be made to enable students with disabilities to take scheduled resit examinations;

(viii) Nevertheless, it was noted that in this instance, the process of setting, marking and moderating a special exam would take the equivalent of 60 staff hours and if it were required that special resit papers for individual students with particular characteristics (i.e. transgender students) should be set, to be taken outside the calendared exam periods, it would be necessary as a matter of fairness to offer this service to other students with disabilities, protected characteristics or general illness who were unable to take scheduled resits

[…]

In relation to the supplementary ground of complaint:

(i) That there would be no reason for any member of Warwick Medical School staff to anticipate this level of failure;

(ii) That advice given to [B] by the Senior Tutor made clear that early scheduling of treatment would incur a risk and that [B] should consider her degree of confidence in passing the exams, before scheduling her elective treatment;

(iii) The Committee was therefore satisfied that the advice given by the Senior Tutor was appropriate.

Particularly unimpressive is the assumption that students such as B can afford (in financial as well as emotional terms) an entire year out from study, and the implication that a decision in her favour would set an awful precedent in which the University would have to appropriately support disabled students.

Concluding thoughts

I find the handling of this whole affair by WMS and the wider University of Warwick to be quite disturbing.

Of course medical courses should be difficult, and of course exams should be stringent. But everyone should have an equal chance to pass (and fail!) them.

Of course University departments have limited time, resources and money, particularly at this time of financial crisis. But they’ve had to spend a whole lot of time and money on this appeal, and they’re going to have to spend more on dealing with the fallout from this case.

I’ve tried to keep this post relatively succinct. It’s inevitably ended up being pretty long, but there’s so much background to this, and so much I haven’t been able to cover. The general impression I get is that WMS (and the University of Warwick) were keen to bury this case underneath a mountain of bureaucracy. The fact that it even reached the appeal stage is a minor miracle.

My concern now is not just for B, but for future students at WMS. I’ve seen a lot of evidence that suggests they don’t take discrimination seriously enough. Let’s hope that in the wake of this we might see policy change to ensure otherwise.

If you wish to contact WMS about this affair, please do. But please do not send any hate mail or threats!

* The student in question wishes to remain anonymous at the time of writing.

A review of England’s draft protocol for gender dysphoria services by CL. You can read a copy of the draft protocol here, respond to the survey here, and read my own analysis here.

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Following the lead of an information note published by the department of health, the draft protocol confirms and compounds the problems of treating gender dysphoria on the NHS. It would at least mostly standardise treatment protocols across England, burdening everyone with the same problems: We’re all in this together, right?

The Gender Services Clinical Reference Group is aiming to implement standardised service provision by April 2013 and has given interested groups until September 30 to respond. GIRES has responded, as has Terrence Higgins Trust’s Trans* Women’s Sexual Health and Wellbeing Group, whose submission I contributed to. Our issues with the Department of Health’s Information Note are seen again here, and I’d like to focus on those in particular: the framing, tailoring and requirements of treatment.
Framing Gender Services Treatment

A problem in the protocol that has carried over from the information note and current practice, is the framing of gender dysphoria treatment as the property of psychiatric specialists. Even in updating the condition being treated to ‘gender dysphoria’ from Gender Identity Disorder, which explicitly frames the problem as one with our gender identities rather than our physical characteristics and the dysphoria resulting from them, the protocol places gender dysphoric people under the care of “a mental health professional (eg. psychiatrist or psychologist) who specialises in transsexualism/gender dysphoria and has general clinical competence in diagnosis and treatment of mental or emotional disorders.”

The logic behind this in the current protocol is not forthcoming. Perhaps it is because there’s a likelihood of additional mental health issues due to the stress of dysphoria. Realistically, it’s because dysphoric people have always been treated as mentally ill, and tradition has kept us under the exclusive care of psychiatrists.

Assessment is a large part of the GICs role: confirming that we have Gender Dysphoria and are not merely deluded about our gender identities. Gender Dysphoria strong enough to necessitate transition is rare, certainly, and doctors are warned to be warey of ‘Zebra diagnoses’ (as House of God, the inspiration for ‘Scrubs’ described them). That is, when you hear hooves, think horse, not zebra. That’s sensible advice, but if you’re in southern African plains, thinking Zebra first might not be so unreasonable. In this case, if someone is distressed by their assigned gender and sexed body, identifies strongly as another gender and feels relief when living as that gender, a diagnosis of ‘trans*’ is the most likely answer. Trusting this principle would rob the GICs of hours of questions about your childhood hobbies and masturbatory habits, but it would free up a lot of unnecessary appointments.

Scotland has already moved away from the complete ownership of Gender Services by mental health teams, allowing patients to self refer to a GIC. This saves an appointment with a GP, one with a community mental health team and allows direct access. For those who need a diagnosis, removing these two stages of waiting, where ignorance or prejudice can delay or waylay a patient, can get them that diagnosis quicker. Given the burden on admin staff and funding, a time, appointment and money saving move like that is far better than the protocol’s recommendations.

Tailoring Service

The introduction to the protocol claims that it is ‘informed by the 7th edition of the WPATH Standards of Care’ – sadly, it isn’t based on them. Some key recommendations from the 7th SOC were: HRT could be prescribed without RLE and one assessment, Lower Surgery required only one year of RLE (rather, one year of HRT). None of those recommendations are followed here, so the role of the 7th SOC’s ‘informing’ is not apparent. As Ruth points out, this is essentially just the existing Charing Cross treatment.

The protocol makes references to giving patients time to consider other options, other approaches, time to reflect and, of course, the RLE’s time to consolidate. There can be great value in this and many people seek the GIC to explore and understand their gender identity. Chances to really assess their history, feelings and situation can be very valuable. A friend in this situation said that her diagnosis brought her great relief and confirmation of her feelings.

For others though, this is unnecessary. Many others will have thought, reflected and considered extensively, almost exclusively at times, before seeking a GIC: they know who they are and what they need. For them, the numerous stages to access a GIC, double assessments and arbitrary RLE periods merely delay them, take up clinic time and appointments and cause additonal frustration as they wait for their treatment.

Clinics shouldn’t be forcing surgery on everyone at the first appointment, but the slowest common denominator approach is hardly ideal either, and unnecessary, arbitrary waiting is positively detrimental in many cases.

Requirements

Despite the 7th SOC’s ‘informing’ of the protocol (perhaps they were low on coasters?), RLE remains a key feature of the proposed gender services. The protocol is unclear about RLE requirements for HRT, but indicates that full HRT can be prescribed ‘Dependent on whether an individual has socially transitioned in the sense of living full time’ or is likely to ‘do so immanently’. Top surgery needs a year of RLE, lower surgery needs 2 years.

The problems with this are numerous:

It’s arbitrary. There are medical reasons for a year of HRT for lower surgery, but not for living full time in role.

Requirements of being employed have nothing to do with a stable, well founded gender identity.

Whilst individuals vary greatly, some people have considerably more difficulty being read as their gender prior to HRT, and AMAB people are more likely to recieve certain forms of harassment if people read them incorrectly. Forcing people into public facing roles to get the treatment they need puts them at direct risk of violence, harassment and discrimination.

What ‘real life’ is being experienced? From my own and others’ experience, I know that living full time as a woman pre HRT is vastly different to being full-time after a year on HRT. The near daily abuse and marginalisation, with incumbent stress, is not the real life I’m experiencing now, but was a feature of living as a woman who was visibly trans*. The RLE required is entirely unrepresentative.

For all the regional variation and obfustication, the 2 years of RLE for surgery is well known, and patients work to it. The lengthy requirement can prompt patients to ‘start the clock’ running on RLE long before they are ready. Who knows how much suffering has come from that, or from knowing that no help will come before an arbitrary deadline?

Patients remain on the GIC’s book during this period: the aforementioned zebras get called in for appointments to needlessly check that they’re still serious, then sent away to wait another 5 months. This takes up appointments that could help patients who are less certain of their needs.

Overall, this protocol standardises existing Charing Cross treatment, which is already behind the times in not adjusting to WPATH’s SOC 7, and seems particularly inadequate when compared to the updated Scottish protocol. Most worryingly, its requirements standardise the appointments that add to the waiting times, administrative burden (which currently means Charing Cross are taking 2-3 months to send appointment summaries) and sense of disempowerment that service users experience. With multiple screenings, assessment and ‘time for reflection’, it is particularly unsuited to those who have a clear understanding of their identity and wish to proceed, and who have thought over their option extensively prior to seeking a referral. If this protocol is to last for any significant time, it will hold service users to standards that are already inadequate – If the next update will last, we need to fight for a protocol that truly moves treatment forward, so make sure to give your views in the protocol’s survey.

The Scottish protocol appears to have been based largely upon the services offered by Sandyford, the nation’s largest gender identity clinic. The English protocol seems rooted in current practice at Charing Cross, which plays a similar role within England and Wales. The differences between the documents hinge largely on the differences between the progressive policies instituted at Sandyford, and the more conservative attitude of Charing Cross.

In this article I’m going to examine some aspects of the draft English protocol that have really struck me, before discussing political elements of difference between the English and Scottish protocols. I also briefly talk about the survey that is being distributed alongside the draft guidance.

The Good

Language – The language used within the draft English protocol largely acknowledges the complexity and diversity of trans experience. It encourages a respect for patient identities in terms of correct name, pronoun usage etc. (regardless of legal status). There’s even an explicit acknowledgement of non-binary identities, although this is somewhat undermined by binary assumptions elsewhere in the document, and a focus upon transitions that follow the typical “female to male” or “male to female” routes.

Referrals – The document provides some important clarifications for referral to a gender clinic: that individuals do not have to have lived in their preferred gender role prior to referral, that neuro-diversity and mental/physical health issues should not be a barrier to referral, and that psychotherapy is not a necessary precursor to referral. However, these points are not made as strongly as they could be, leaving some room for (mis)interpretation.

Treatment process–The document states that two appointments should be sufficient for a diagnosis of gender dysphoria (to be diagnosed according to the ICD-10 criteria, as opposed to DSM-IV). The prescription of hormones should (if appropriate and desired) follow this diagnosis, and surgery should follow within approximately two years. This might all sound very familiar to Charing Cross patients, but may work to reign in some of the more eccentric practices of smaller gender clinics such as Nottingham.

Overall – It will be beneficial to have this protocol at hand to bring local referral practices and the actions of smaller GICs in line with national standards.

The Bad

Referrals – Referrals must come from a GP or specialist (psychiatrist or psychologist), with clinics able to insist upon referral from a specialist. This means that long-winded battles for referral look set to continue as normal. In contrast, the new Scottish system appears allows individuals or GPs to refer to any clinic.

Treatment process – The protocol states that it is informed by the most recent edition of the WPATH Standards of Care. However, it seems (again, contrary to the Scottish protocol) to ignore large parts of the Standards of Care in favour of current Charing Cross practice.

For instance, FtM spectrum individuals must have been on hormones for at least six months and full-time for at least a year before top surgery is considered, and patients must wait at least two years before being offered genital surgery (although a referral appointment for surgery may take place after 18 months under some circumstances). This last point in particular is justified with reference to ICD-10. Interesting here that guidance for diagnosis from 1992 is given precedence over guidance for care from 2011.

Trans youth– There is an acknowledgement of the benefits of hormone blockers for under-18s, but (unlike the Scottish protocol) no real engagement with the possibility of hormones and surgery for trans people aged between 16 and 18. The protocol continues to relegate all young people to specialised – and limited! – youth services.

Overall – The document pays lip service to the WPATH Standards of Care but does not really live up to the spirit of those guidelines. This is particularly evident when the draft document is compared to the Scottish protocol. Patients are expected to put up with a long-winded, complex system in which treatment is spread out over many years.

The Ugly

Get a job – Patients are still expected to be in education or employment in order to gain a referral for genital surgery. If you don’t have a job or you’re not on a course, you’re expected to be involved in some volunteering role. It’s all about demonstrating your ability to move through the world in your “new” gender prior to irreversible surgery.

This requirement is patronising, stupid, and fetishises trans genitals. What other surgery requires that those who undergo it are in work? Why is it that genital reconstruction is seen such a massive step, but the permanent changes that come with long-term hormone therapy is not? Yes, surgery is a big deal, but it’s clear that clinicians regard this surgery as something else entirely.

I can’t understand how this can possibly be acceptable at the best of times, but at a time of recession and mass unemployment it strikes me as particularly cruel and unreasonable. How to account for individuals who cannot find a volunteering role in their local area? Individuals with anxiety issues? Individuals who are told by the Job Centre not to volunteer, with the threat of benefit withdrawal hanging over this order? And how can this possibly be acceptable when trans people face considerable inequalities in the job market (with trans unemployment estimated at 50% in some European countries).

Physical examination – GPs are apparently “expected” to perform a physical examination of trans patients. Why? No reason is given. The document simply states that: “The GP will be required to carry out a basic physical examination and investigations, as a precursor to those physical treatments which may later be recommended.”

I simply cannot comprehend where this idea comes from. For many trans people – particularly those contemplating physical transition – the very idea of a physical examination is extremely unpleasant and can cause severe distress. There are times when pre-operative trans people might require a physical examination: such as immediately prior to surgery, or during a sexual health check-up. These experiences can be deeply unpleasant, but at least they’re necessary.

GPs are not trained to understand the complexities of trans people’s relationships with their bodies. In fact, most GPs don’t receive any training on trans issues whatsoever. What are they meant to be looking out for during such an examination, and how are they supposed to know? An invasive examination such as this should only be performed when necessary, by someone who knows exactly what they’re doing.

Discussion: England vs Scotland

The headlines from the Scottish protocol included a number of moves to bring treatment more in line with the most recent edition of the WPATH Standards of Care. These included provisions for self-referral and referral by GP, less waiting time for surgeries, access to a wider range of treatments (e.g. hair removal) and full access to treatment for individuals aged between 16 and 18.

Whilst representatives from groups such as the Scottish Transgender Network played a vital role in putting provisions such as these on the national agenda, it’s important to recognise that many of them had already been implemented by Sandyford GIC.

The message seems to be that the English clinics – who are almost entirely responsible for the development of this draft protocol – are not interested in developing new practice, let alone conforming with the seventh edition of the WPATH Standards of Care. Instead, they seem keen to maintain a tight control over the processing of patients, an approach that renders the draft protocol even more strict than a new national commissioning policy that is being simultaneously developed.

Survey

The survey that accompanies the draft protocol is extremely short. This makes it quick and easy to fill in, but the form also seems to have been designed to shut down unwanted criticism. The Department of Health appears interested only in how current experiences match up to the proposed protocol, and seems keen to avoid any kind of critical feedback on the document.

It is, however, possible to offer you opinion on the nature of the protocol itself. Here are some tips for doing so:

Where your experiences differ from the protocol in a positive manner (e.g. you didn’t receive a physical examination from your GP), emphasise how your experience was more positive than would be the case should the protocol be implemented as-is.

Where your experiences differ from the protocol in a negative way, emphasise any manner in which you think the protocol could go further to ensure better treatment.

If you have sought care outside of the NHS for necessary treatments (e.g. hair removal for trans women) explain why this treatment should be a necessary part of the protocol

Final thoughts

The introductory text to the survey suggests that current political and financial pressures on the NHS prohibit the introduction of any real changes within the draft protocol:

DH wants the final document to outline the current position for transgender people seeking gender reassignment services through the NHS. The document should outline what support and services a transgender person can expect to receive in the tight financial constraints currently placed on the NHS.

This doesn’t really make a huge amount of sense. Yes, if more trans people have access to services (e.g. laser hair removal), this will cost money. But surely there is a lot more money to be saved through progressive reform?

Insisting on longer real-life tests, longer waits for surgery and so on won’t save a lot of money in the long term. A similar amount of trans people will be accessing services: they’ll just have to wait longeras individuals in order to access the a services. The money will still be spent. So why have such long waiting times?

Insisting on referral through a specialist (i.e. psychiatrist or psychologist) won’t save money. How does the NHS possibly benefit financially from insisting that trans people see more specialists rather than having them directly referred to a gender clinic by their GP? This is particularly the case when specialists decide that they need to assess people over multiple appointments before referring them to a gender clinic. The individuals concerned experience a frustrating delay, and it costs more money because the NHS is paying for all these extra appointments.

This isn’t really about the money. It’s about gatekeepers maintaining a certain level of control over patients, and putting certain ideologies into practice. It’s about picking and choosing which parts of ICD-10 and WPATH SOC 7 fit best with their pre-existing ideas, and using those elements to justify existing practice. It’s about conservativism over progression: a wasted opportunity.

The Sun is in trouble. Years of journalistic malpractice are finally catching up with the venerable tabloid, with employees arrested en-masse on “suspicion” of corruption and bribery.

Associate editor Trevor Kavanagh is upset about this. “Witch-hunt has put us behind ex-Soviet states on Press Freedom”, his editorial thunders. It goes on to detail the humiliation experienced by Sun journalists and their families:

“Instead of being called in for questioning, 30 journalists have been needlessly dragged from their beds in dawn raids, arrested and held in police cells while their homes are ransacked. […]

Wives and children have been humiliated as up to 20 officers at a time rip up floorboards and sift through intimate possessions, love letters and entirely private documents. […]

Nobody has been charged with any offence, still less tried or convicted.

Yet all are now on open-ended police bail, their lives disrupted and their careers on hold and potentially ruined.“

Yesterday, I noted a number of issues with the reporting of a British man’s pregnancy and the subsequent birth of his child. It seems, however, that the story simply wasn’t exciting enough for The Telegraph, who have revised their article somewhat overnight.

(click above for full-sized image)

The story itself remains largely unchanged: there is no new information. The only difference I could pick out was the introductory paragraph, which has changed one phrase in order to turn this somewhat inaccurate but broadly inoffensive sentence:

“The man, who is believed to be in his 30s, was able to carry a child after taking female hormones to reverse the effects of his female-to-male sex change treatment. “

…into something which takes that extra step to question the subject’s gender.

“The ‘male mother’, who is believed to be in his 30s, was able to carry a child after taking female hormones to reverse the effects of his female-to-male sex change treatment.“

Somewhat bizarrely, the original story remains online, possibly because The Telegraph wouldn’t dare offend the hundreds of readers who took time to comment on how disgusting it is that trans people want to mutilate their bodies.

Yesterday I was prepared to concede that Telegraph journalists were content to merely be stupid and lazy on trans issues. It turns out, however, that they’re actually prepared to put effort into their transphobic bigotry. Well done all.